Provider Demographics
NPI:1871131359
Name:MARTYNCHUK, VOLODYMYR
Entity type:Individual
Prefix:
First Name:VOLODYMYR
Middle Name:
Last Name:MARTYNCHUK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MONTGOMERY AVE APT 8B
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-2659
Mailing Address - Country:US
Mailing Address - Phone:818-219-4538
Mailing Address - Fax:
Practice Address - Street 1:4170 CITY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1610
Practice Address - Country:US
Practice Address - Phone:215-871-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA005403363A00000X
390200000X
PAMA062023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program